Nokea
How many factors in this scenario place the client at risk for nutritional deficiencies and the need for dietary guidance and counseling?
- A. Three
- B. Four
- C. Five
- D. Six
Correct Answer: C
Rationale: Five risk factors: adolescence, skipping meals, fast food diet, alcohol consumption, and weight gain concerns increase nutritional deficiency risk.
You may also like to solve these questions
The oncoming shift nurse assesses the fundus of the postpartum client 6 hours after a vaginal birth and finds that it is firm. When the nurse then assists the client out of bed for the first time, blood begins to run down the client’s leg. Which action by the nurse in response to the client’s bleeding is correct?
- A. Explain that extra bleeding can occur with initial standing
- B. Immediately assist the client back into bed
- C. Push the emergency call light in the room
- D. Call the HCP to report this increased bleeding
Correct Answer: A
Rationale: Lochia normally pools in the vagina when the postpartum client remains in a recumbent position for any length of time. When the client then stands, gravity causes the blood to flow out. As long as the nurse knows the fundus is firm and not bleeding, a simple explanation to the client is all that is required. There is no reason to return the client to bed; the fundus is firm. There is no reason to push the emergency call light. Increased bleeding is an expected response when standing for the first time. There is no reason to call the HCP.
At one minute after birth, a neonate is pink, except for blue extremities. The neonate is crying, gagging, and grimacing when the bulb syringe is used and has some flexion of extremities and an HR of 97. Based on the Apgar score, what should the nurse do next?
- A. Notify the health care provider
- B. Recheck the Apgar at 5 minutes after birth
- C. Initiate resuscitation measures immediately
- D. Swaddle and hand to mother for breastfeeding
Correct Answer: B
Rationale: Rechecking the Apgar score at 5 minutes after birth will determine if the newborn is continuing to make a good transition to the extrauterine environment. Notifying the HCP is not necessary at this time. The one-minute Apgar score is 6, very close to the 7 to 10 normal limits. This newborn has a good cry, indicating good transition to the extrauterine environment thus far. Initiating resuscitation measures immediately is not necessary. This would be done if the newborn were not crying and demonstrated a blue or pale body. Swaddling and giving the newborn to the mother for breastfeeding are important but should occur after the 5-minute Apgar, if the score is WNL. Keeping this newborn in the radiant warmer, rather than giving him or her to the mother, will help prevent hypothermia and promote better transition to extrauterine life.
The nurse identifies which factor as increasing the risk of gestational hypertension?
- A. Low body mass index
- B. Family history of hypertension
- C. First pregnancy at age 20
- D. Vegetarian diet
Correct Answer: B
Rationale: A family history of hypertension increases the risk of gestational hypertension, as genetics play a significant role.
The 29-weeks-pregnant client presents to triage with decreased fetal movement. Her initial BP is 140/90 mm Hg. She states she “doesn’t feel well” and her vision is “blurry.” Additional assessment findings include: normal reflexes, +2 proteinuria, trace pedal edema, and puffy face and hands. What is the most important information that the nurse should obtain from the client’s prenatal record?
- A. Depressed liver enzymes
- B. BP at her first prenatal visit
- C. Urine dipstick from last visit
- D. The pattern of weight gain
Correct Answer: B
Rationale: The pregnant client with a BP that is greater than 140/90 mm Hg with the presence of proteinuria may have preeclampsia. New-onset hypertension is associated with preeclampsia. Generalized vasospasm in preeclampsia would result in reduced blood flow to the liver and elevated, not depressed, liver enzymes. The urine dip from the last visit should be reviewed but is not the most important to review because the significant information is the client’s elevated BP. The weight gain pattern should be reviewed but is not the most important to review because the significant information is the client’s elevated BP.
The nurse prepares the client for which pain management option during labor?
- A. Epidural anesthesia
- B. Hot baths during active labor
- C. Over-the-counter pain relievers
- D. No pain relief options
Correct Answer: A
Rationale: Epidural anesthesia is a common and effective pain management option during labor, tailored to the client's needs.